Estradiol metabolism in cirrhosis

An Overview of the Molecular Mechanisms Contributing to Musculoskeletal Disorders in Chronic Liver Disease: Osteoporosis, Sarcopenia, and Osteoporotic Sarcopenia

The prevalence of osteoporosis and sarcopenia is significantly higher in patients with liver disease than in those without liver disease and osteoporosis and sarcopenia negatively influence morbidity and mortality in liver disease, yet these musculoskeletal disorders are frequently overlooked in clinical practice for patients with chronic liver disease. The objective of this review is to provide a comprehensive understanding of the molecular mechanisms of musculoskeletal disorders accompanying the pathogenesis of liver disease. The increased bone resorption through the receptor activator of nuclear factor kappa (RANK)-RANK ligand (RANKL)-osteoprotegerin (OPG) system and upregulation of inflammatory cytokines and decreased bone formation through increased bilirubin and sclerostin and lower insulin-like growth factor-1 are important mechanisms for osteoporosis in patients with liver disease. Sarcopenia is associated with insulin resistance and obesity in non-alcoholic fatty liver disease, whereas hyperammonemia, low amount of branched chain amino acids, and hypogonadism contributes to sarcopenia in liver cirrhosis. The bidirectional crosstalk between muscle and bone through myostatin, irisin, β-aminoisobutyric acid (BAIBA), osteocalcin, as well as the activation of the RANK and the Wnt/β-catenin pathways are associated with osteosarcopenia. The increased understandings for these musculoskeletal disorders would be contributes to the development of effective therapies targeting the pathophysiological mechanism involved.

Sex Differences in Portopulmonary Hypertension

BACKGROUND

Portopulmonary hypertension (POPH), pulmonary arterial hypertension that develops in the setting of portal hypertension, can lead to right-sided heart failure and death. Being female is a known risk factor for POPH, but little is known about the effect of sex on clinical manifestations, hemodynamics, treatment response, and survival.

RESEARCH QUESTION

We sought to characterize sex differences in clinical characteristics, pulmonary hemodynamics, treatment response, and survival in patients with POPH.

STUDY DESIGN AND METHODS

We performed a retrospective cohort study of adult candidates for liver transplant (LT) who had POPH within the Organ Procurement and Transplantation Network database. Females and males were compared. Multivariate regression was performed to assess the association between sex and pulmonary vascular resistance (PVR) and survival. Patients were also stratified by age (50 years) to determine how age modifies the relationship between sex and hemodynamics and survival.

RESULTS

We included 190 adults (103 male, 87 female). Compared with men, women had a lower model for end-stage liver disease (MELD) score (12.1± 4.2 vs 13.8 ± 4.9; P = .01) and were more likely to have autoimmune liver disease. Women had a higher baseline PVR (610.6 ± 366.6 vs 461.0 ± 185.3 dynes-s-cm^-5; P < .001) and posttreatment PVR (244.6 ± 119.5 vs 202.0 ± 87.7 dynes-s-cm^-5; P = .008) and a greater treatment response (ΔPVR) (-359.3 ± 381.9 vs -260.2 ± 177.3 dynes-s-cm^-5; P = .03). In multivariate analysis, female sex (or gender) remained associated with a higher baseline PVR (P = .008). Women and men had overall similar survival (P > .05). When patients were stratified by age, being female was independently associated with worse waiting list survival after adjusting for MELD and PVR in younger patients (HR, 6.61; 95% CI, 1.25-35.08; P = .03) but not in older patients.

INTERPRETATION

Compared with male candidates, female candidates for LT who had POPH had a higher PVR and lower MELD score and were more likely to have autoimmune liver disease. Women and men had similar overall survival, but female sex (or gender) was associated with worse survival in younger patients.

Sex Differences in the Regulation of Vasopressin and Oxytocin Secretion in Bile Duct-Ligated Rats

INTRODUCTION

Hyponatremia due to elevated arginine vasopressin (AVP) secretion increases mortality in liver failure patients. No previous studies have addressed sex differences in hyponatremia in liver failure animal models.

OBJECTIVE

This study addressed this gap in our understanding of the potential sex differences in hyponatremia associated with increased AVP secretion.

METHODS

This study tested the role of sex in the development of hyponatremia using adult male, female, and ovariectomized (OVX) female bile duct-ligated (BDL) rats.

RESULTS

All BDL rats had significantly increased liver to body weight ratios compared to sham controls. Male BDL rats had hyponatremia with significant increases in plasma copeptin and FosB expression in supraoptic AVP neurons compared to male shams (all p < 0.05; 5-7). Female BDL rats did not become hyponatremic or demonstrate increased supraoptic AVP neuron activation and copeptin secretion compared to female shams. Plasma oxytocin was significantly higher in female BDL rats compared to female sham (p < 0.05; 6-10). This increase was not observed in male BDL rats. Ovariectomy significantly decreased plasma estradiol in sham rats compared to intact female sham (p < 0.05; 6-10). However, circulating estradiol was significantly elevated in OVX BDL rats compared to the OVX and female shams (p < 0.05; 6-10). Adrenal estradiol, testosterone, and dehydroepiandrosterone (DHEA) were measured to identify a possible source of circulating estradiol in OVX BDL rats. The OVX BDL rats had significantly increased adrenal estradiol along with significantly decreased adrenal testosterone and DHEA compared to OVX shams (all p < 0.05; 6-7). Plasma osmolality, hematocrit, copeptin, and AVP neuron activation were not significantly different between OVX BDL and OVX shams. Plasma oxytocin was significantly higher in OVX BDL rats compared to OVX sham.

CONCLUSIONS

Our results show that unlike male BDL rats, female and OVX BDL rats did not develop hyponatremia, supraoptic AVP neuron activation, or increased copeptin secretion compared to female shams. Adrenal estradiol might have compensated for the lack of ovarian estrogens in OVX BDL rats.

Bone Diseases in Patients with Chronic Liver Disease

Osteoporosis is a frequently observed complication in patients with chronic liver disease, particularly liver cirrhosis and cholestatic liver diseases. In addition, osteoporosis is critical in patients receiving a liver transplant. Nevertheless, few studies have evaluated bone diseases in patients with more frequently observed chronic liver disease, such as chronic viral hepatitis, nonalcoholic fatty liver disease and alcoholic liver disease. Osteoporosis is a disease caused by an imbalance in the activities of osteoblasts and osteoclasts. Over the last few decades, many advances have improved our knowledge of the pathogenesis of osteoporosis. Importantly, activated immune cells affect the progression of osteoporosis, and chronic inflammation may exert an additional effect on the existing pathophysiology of osteoporosis. The microbiota of the intestinal tract may also affect the progression of bone loss in patients with chronic liver disease. Recently, studies regarding the effects of chronic inflammation on dysbiosis in bone diseases have been conducted. However, mechanisms underlying osteoporosis in patients with chronic liver disease are complex and precise mechanisms remain unknown. The following special considerations in patients with chronic liver disease are reviewed: bone diseases in patients who underwent a liver transplant, the association between chronic hepatitis B virus infection treatment and bone diseases, the association between sarcopenia and bone diseases in patients with chronic liver disease, and the association between chronic liver disease and avascular necrosis of the hip. Few guidelines are currently available for the management of low bone mineral density or bone diseases in patients with chronic liver disease. Due to increased life expectancy and therapeutic advances in chronic liver disease, the importance of managing osteoporosis and other bone diseases in patients with chronic liver disease is expected to increase. Consequently, specific guidelines need to be established in the near future.

Female Sex Hormones Pattern and Its Relation to Disease Severity and Treatment in Pre- and Postmenopausal Patients with Chronic Hepatitis C Virus (Genotype 4) Infection

Chronic hepatitis C (CHC) course revealed differences between men and women. Male gender and postmenopausal women are thought to be of the critical factors affecting HCV infection progression. The study aimed to assess female sex hormones and their relation to disease severity and treatment in HCV infected females. Subjects were divided to 2 groups: 44 CHC female patients and 44 controls. Both groups were classified to premenopausal and postmenopausal females. Serum estradiol (E2), progesterone (PRG), and total testosterone (TT) were assessed using chemiluminescent immunoassay. Our results showed that menopausal patients had significantly higher levels of estradiol, total testosterone, and progesterone compared to controls (P < 0.001). Reproductive aged patients had lower level of total testosterone compared to menopausal patients (P < 0.001). HCV infected females of reproductive age had higher level of progesterone compared to menopausal HCV infected females (P = 0.0014). Indicators of disease severity and treatment response were significantly worse in menopausal women compared to reproductive aged women (fibrosis: P < 0.001, activity: P = 0.045, and treatment: P < 0.001). We observed that lower estradiol level may be related to fibrosis severity in CHC females. Higher total testosterone and progesterone levels may be related to fibrosis severity and poor response to treatment in CHC menopausal females only.

Osteoporosis and fractures in liver disease: Relevance, pathogenesis and therapeutic implications

It is being increasingly recognized that patients with liver disease develop bone loss that can be severe enough to lead to atraumatic fractures and thus markedly diminish life quality and expectancy. The estimated prevalence for liver-related osteoporosis is between 20-420/100000 of the general population, and fractures between 60-880/100000. It should be kept in mind that up to 40% of patients with chronic liver disease may experience a fracture. The pathogenic mediators include fibronectin, insulin like growth factor-I, and various cytokines, but decreased vitamin D and/or treatment with corticosteroids contribute to worsening bone health. Despite the advances in bone biology that have shed some light on the pathogenesis of this bone loss, treatment options remain nonspecific and tightly linked to treatments of other forms of osteoporosis. Thus, treatment should include calcium and vitamin D supplementation in all patients with chronic liver disease. Therapy with bisphosphonates should be considered, especially in patients receiving corticosteroids. This review focuses on the prevalence of this entity as well as the evidence available with regard to the pathogenesis of bone loss in liver disease, the diagnostic steps required in all patients, and the therapeutic options available.

Clues to understanding the oxidation of estradiol in humans: effects of acute infectious hepatitis, autoimmune hepatitis, and chronic liver disease

Determination of 2- and 16alpha-hydroxylation of estradiol in patients with a variety of liver disorders using a dynamic method of quantitating the extent of hydroxylation revealed specific and characteristic differences in the metabolic response. Patients with acute or silent variants of hepatitis B had estrogen metabolite patterns that were indistinguishable from those found in the control subjects. Female patients with autoimmune hepatitis (formerly known as lupoid hepatitis), however, showed a moderate significant decrease (P < 0.01) in 2-hydroxylation as compared with normal controls (mean 16.3 +/- 1.9 vs. 33.9 +/- 2.5), with no significant change in 16alpha-hydroxylation. Male and female subjects with chronic alcoholic cirrhosis were almost devoid of 2-hydroxylation (mean 2.9 +/- 0.5, P < 0.01), but did show a significant increase in 16alpha-hydroxylation (P < 0.01). The results, therefore, show that the alterations in patterns of biological oxidation are highly specific and do not reflect a general inability to metabolize estrogens in the cirrhotic patient. However, the results also suggest the possibility that a substantial fraction of 16alpha-hydroxylation may occur elsewhere in the body at sites other than in the liver, explaining why this biotransformation pathway is elevated, while the reaction at C-2 is almost absent in the alcoholic cirrhotic subjects.

Interactions between clinically used drugs and oral contraceptives

Metabolism of contraceptive compounds may be influenced by various drugs. Of clinical importance is induction by barbiturates, by diphenylhydantoin, and especially by rifampicin, of enzymes that are responsible for degradation of estrogens. The major target is the hepatic microsomal estrogen-2-hydroxylase (cytochrome P450 3A4). Another type of interaction of drugs with disposition and effectiveness of estrogens is impairment of their enterohepatic circulation. This may be due to absorption of biliary estrogen conjugates (e.g., by cholestyramine) or to insufficient cleavage of the conjugate by intestinal bacteria, the latter being observed after administration of antibiotics (e.g., ampicillin, neomycin).

A method for estimating catechol estrogen metabolism from excretion of noncatechol estrogens

The relationship of catechol estrogen metabolism to disease has seldom been investigated because of analytic difficulties. Estradiol (E2) and estrone (E1) are oxidized simultaneously at either ring A or ring D, and the rate of catechol estrogen formation (r2) is reciprocally related to the rate of 16 alpha-hydroxylation (r3). The rate of ovarian estrogen production (X10) can be summarized as to metabolic outcome: X10 = r10 + r2 + r3 + r(u), where r10 is the loss of E1 and E2 in urine, and ru is the fecal and urinary loss of unknown oxidative products. Assuming a constant r(u) between subjects: constancy of the X10 concentration between subjects during similar menstrual cycle phases. In the absence of xenobiotics, r2 x r3 are reciprocally interrelated: r2 x r3 = K (an oxidation constant whose limiting factor is the biologically available estrogen at the cell surface). To the extent that r10 approximates estrogens available for cellular metabolism, the rate of catechol estrogen metabolism may be determined from (Formula; see text) From published data K = 12.4 +/- 0.8 of the standard error of the mean. Pearson correlation coefficients between actual and estimated catechol estrogen excretion in groups of subjects ranged from 0.61 to 0.97 (median, 0.88). This method has been useful for clinical investigation of the relationship of catechol estrogen metabolism to disease until better methods to measure catechol estrogen directly are available.

Separation of urinary metabolites of radiolabelled estrogens in man by HPLC

A method to separate radiolabelled urinary estrogens by high performance liquid chromatography (HPLC) is described. Estrogen glucuronides were isolated from the urine of women receiving bolus injections of [4-14C]estrone or [4-14C]estradiol by adsorption on Sep-Pak C18 cartridges and subsequent DEAE Sephadex A25 column chromatography. Following enzyme hydrolysis, free estrogens were extracted and concentrated in methanol-water containing ascorbic acid. HPLC was performed either by C18 reversed phase chromatography using different concentrations of acetonitrile with or without tetrahydrofurane in phosphate buffer or methanol-water as mobile phases, or on a Diol column using chloroform-isooctane-n-hexane or isopropanol-isooctane-n-hexane as mobile phases. 3H-labelled estrogens were added as internal standards, and urinary [14C]estriol, [14C]estradiol and [14C]estrone concentrations could be measured with an interassay coefficient of variation less than 5%. Interassay coefficients of variation for [14C]2-hydroxyestriol, [14C]16 alpha-hydroxyestrone, [14C]2-hydroxyestradiol, [14C]2-hydroxyestrone and [14C]2-methoxyestrone were between 5 and 10%, while interassay coefficients of variation for [14C]4-hydroxyestrone was 14.6%. Recovery of the unstable catechol estrogen 2-hydroxyestrone was comparable to the recovery of the other estrogen metabolites, due to the addition of ascorbic acid throughout the different pre-chromatographic steps. Our method is suitable for the separation of the major labelled estrogen metabolites found in human urine following administration of radiolabelled estrone or estradiol.

Metabolism of estradiol by human breast cancer

The activities of estrogen-2,4- and 16 alpha-hydroxylase as well as 17 beta-hydroxysteroid dehydrogenase (17 beta-OHSDHase) were determined in normal, benign and mammary tumor breast tissues. All three hydroxylases were absent in both normal and benign tumor breast tissues. 17 beta-OHSDHase was absent from normal breast tissues but present in all benign tumor tissues. Estrogen-2-hydroxylase was present in most breast carcinomas, was significantly higher in estrogen receptor (ER)-positive than ER-negative tumors, did not correlate with progesterone receptor (PR) and was significantly lower in the ER+PR- subgroup of breast cancers. 4-Hydroxylase activity did not correlate with either ER or PR content but was significantly lower in the ER+PR- subgroup of breast cancers. The activity of 16 alpha-hydroxylase was present in only 18% of all tumors investigated (9/50), did not correlate with the ER or PR content and was completely absent in the ER+PR- and ER-PR+ subgroups. The activity of 17 beta-OHSDHase was significantly higher than the estrogen hydroxylase but did not correlate with either the ER or PR content, and was not different among the ERPR tumor subgroups. The physiological role of these enzymes in the metabolism of estradiol in relation to breast cancer is discussed.

Increased urinary catechol estrogen excretion in female smokers

Premenopausal female smokers show significantly increased estrogen 2-hydroxylation, which may account in part for the anti-estrogenic effects of cigarette smoking. We have measured five major urinary estrogens, including estradiol (E2), estrone (E1), 16 alpha-hydroxyestrone (16 alpha OHE1), estriol (E3), and 2-hydroxyestrone (2OHE1), in premenopausal female smokers and non-smokers, to determine whether increased C-2 hydroxylation affected the urinary excretory patterns in these subjects. While total measured estrogen excretion in the follicular phase did not differ significantly between the two groups, urinary 2OHE1 among the smokers constituted a significantly greater proportion of the total (31.1 vs 18.2%, P less than 0.02). This difference was largely caused by significantly increased urinary 2OHE1 and decreased E3 observed in smokers. A urinary catechol estrogen index, defined by [2OHE1]/[E3], was significantly elevated in smokers compared with non-smokers (1.67 +/- 0.21 vs 0.56 +/- 0.08, P less than 0.001), and this urinary index correlated strongly with radiometrically determined estrogen 2-hydroxylation (r = 0.84, P less than 0.01). Ratios of the various estrogen metabolites did not vary substantially throughout the menstrual cycle. Urinary estrogen indices as described here may therefore be useful in demonstrating differences in estrogen metabolism, specifically 2-hydroxylation vs 16 alpha-hydroxylation, in selected populations.

The multicomponent analysis of estrogens in urine by ion exchange chromatography and GC-MS--I. Quantitation of estrogens after initial hydrolysis of conjugates

A method for the multicomponent analysis of estrogens in urine after initial hydrolysis of the conjugates is described. Following protection of the carbonyl functions by ethoximation, estrogen conjugates were extracted on Sep-Pak C18 cartridges and purified on the acetate form of DEAE-Sephadex. The samples were subsequently hydrolysed by Helix pomatia juice and the hydrolysate was purified on the acetate form of QAE-Sephadex. Estrogens with vicinal cis-hydroxyls and diphenolic compounds were fractionated on the borate and bicarbonate form of QAE-Sephadex, respectively. Neutral steroids were removed by the free base form of DEAE-Sephadex after which estrogens were separated into two groups using Lipidex 5000 in a straight phase system. Following trimethylsilyl ether derivatization estrogens were analysed by selected ion monitoring (SIM). The method allows the quantitation of all the important estrogen metabolites including catechol estrogens. It is precise, accurate and sensitive permitting the quantitation of estrogens in urine of males and non-pregnant females.

Clinical evaluation of thyroxine-binding globulin (TBG) as a marker of liver tumors

This investigation was undertaken to evaluate thyroxine-binding globulin (TBG) as a marker of liver tumors, in conjunction with the liver scintigram. Of 30 patients with primary hepatocellular carcinoma (PHC), 22 (73.3%) showed significantly higher TBG concentrations. Eight patients (26.7%) showed normal TBG concentrations. In the case of 27 out of 30 patients with definite liver tumors, defects were apparent on the scintigrams. But seven of them had normal TBG concentrations in spite of the defects on the scintigrams. Out of 33 postoperative patients with liver metastasis, 28 (84.8%) had a raised TBG concentration. Only five (15.2%) had a normal TBG level. In 31 patients (93.9%) out of 33 with liver metastasis, a definite diagnosis was made on the basis of the liver scintigram. In 28 (90.3%) of these 31 people, the TBG concentration was higher than normal. Among 63 patients with liver tumors, both primary and metastatic, the test sensitivity for liver tumors was 92.1% (58/63) based on the accuracy of the liver scintigram. It was 79.4% (50/63) based on the TBG measurement. Why TBG increases to such an extent in spite of the euthyroid state remains unexplained. But it may be concluded that elevated TBG with positive liver scintigram furnishes a sensitive, fairly reliable, nonspecific tumor marker to determine liver tumors, especially in the case of liver metastasis.

Drug control of steroid metabolism by the hepatic endoplasmic reticulum

In this review evidence is provided for the interaction between various drugs and steroid hormones in man and between drugs and progestogens in experimental animals. The mechanism by which these drug interactions occur are of fundamental biochemical and pharmacological interest. The importance of practical clinical considerations of drug-steroid interactions has also been discussed. In particular, considering the present tendency to lower the dose of progestogen and estrogen in most contraceptive preparations, any factor that reduces the bioavailability of the steroid hormones becomes very important. Other drugs and environmental chemicals may interact with these steroids and thereby diminish their efficacy. Clinical studies have reported that the most important interfering drugs are some anticonvulsants and antibiotics, and the antituberculosis compound rifampicin. Anticonvulsants and antituberculotics affect microsomal enzyme induction in the liver or interfere with enzyme systems in the gut wall. The action of antibiotics is connected with the pharmacokinetics of contraceptive steroids by an interaction with their enterohepatic circulation. Some environmental factors such as smoking, alcohol, and other dietary variations, and concurrent hepatic disease may modify the disposition of circulating endogenous steroids and exogenous contraceptive steroids. These effects may alter their response accordingly. In our studies drug treatments of rats reduced serum progesterone level irrespective of whether a potent inducer (phenobarbital, 4-methylcoumarin) or a hepatotoxin (carbon tetrachloride, coumarin, alpha-naphthylisothiocyanate) was administered. These treatments affected hepatic progesterone content. Phenobarbital and carbon tetrachloride reduced serum level, but the hepatic incorporation was enhanced by phenobarbital and reduced by carbon tetrachloride. The opposite actions were selective; phenobarbital raised the oxidative pathway of progesterone metabolism but did not modify the reductive pathway. This drug also enhanced progesterone 16 alpha-, 6 beta-, and 20 alpha-hydroxylase, but did not alter delta 4 - 5 alpha-reductase. In contrast, carbon tetrachloride inhibited hydroxylase and enhanced reductase activities. The effects of these test compounds on progesterone-metabolizing enzymes in isolated microsomes in vitro were similar to the in vivo results. It is concluded that the action of various drugs on serum and liver progesterone levels and metabolism is probably related to changes manifest in the function of the hepatic endoplasmic reticulum.

Liver damage and sex hormones in chronic male alcoholics

The hormonal status of thirteen chronic male alcoholics with histologically proved alcoholic liver cirrhosis and that of sixteen non-cirrhotic chronic alcoholics with a similar drinking history were studied after the abstinence of 7-14 days. Low levels of plasma testosterone and moderately elevated concentrations of plasma LH were seen in cirrhotics but not in non-cirrhotics. In cirrhotics, testosterone values showed positive correlations with levels of serum albumin and plasma prothrombin. The responses of LH and FSH secretions to LHRH stimulation were similar in the two groups as were the basal FSH values. Plasma concentrations of oestradiol were within normal limits in all patients. In both groups however, basal levels of plasma PRL and oestrone were increased, significantly more so in cirrhotics than in non-cirrhotics. The latter group was characterized by an exaggerated response of PRL secretion to TRH stimulation. SHBG concentrations were within normal range in both groups. In conclusion, our results emphasize the role of alcohol-induced liver damage in the pathogenesis of sex hormone disturbances of chronic male alcoholics without neglecting, however, the direct effects of alcohol abuse itself.

Alterations of estrogen metabolism in systemic lupus erythematosus

Estradiol metabolism in 10 patients with systemic lupus erythematosus (SLE) and 29 normal controls was studied by measurement of urinary metabolites after injection of labeled 3H-estradiol. Patients with SLE manifested increased 16-hydroxylation of estrone. Diseases men differed from diseases women to the extent that only 16 alpha-hydroxyestrone was elevated in men, whereas women had elevations of both 16 alpha-hydroxyestrone and estriol. These data suggest that patients with SLE have abnormal patterns of estradiol metabolism, leading to increased estrogenic activity.

15alpha-Hydroxyoestriol and other polar oestrogens in pregnancy monitoring

Although oestriol measurements are well established for the assessment of 'at risk' pregnancies, there are a number of other oestrogens, excreted during pregnancy, which contain additional hydroxyl groups and might be more sensitive indicators of the condition of mother or fetus. Some of these result from the action of hydroxylases possibly present only in the fetus and others from maternal hydroxylations. We review the evidence for the biosynthesis of these polar oestrogens, summarise methods of measurement, and compare values obtained in normal and pathological pregnancies. There is as yet insufficient evidence to enable their potential value to be confirmed.

Systemic lupus erythematosus associated with klinefelter's syndrome

Studies in estrogen metabolism were carried out in 2 males with systemic lupus erythematosus (SLE) who also had Klinefelter's syndrome. Although these studies revealed elevated levels of urinary estrogens in 1 patient, abnormalities of estradiol metabolism suggesting persistent estrogen stimulation were detected in both. This report notes an association between SLE and Klinefelter's syndrome and suggests that chronic estrogenic stimulation may be significant in the development of SLE in these 2 patients.

Plasma oestrogens in men with chronic liver disease

A highly specific radioimmunoassay was used to measure the total plasma concentrations of the three principal unconjugated oestrogens: oestrone E1, oestradiol E2, and oestriol E3 in normal males and in 21 males with various forms of chronic liver disease. In addition, the unbound concentration of plasma E2 was established in the same group. About half of the patients with liver disease had overt feminising changes. Total and unbound plasma E2 concentrations were within the normal range in all patients. Total plasma E1 was significantly elevated only in those patients with liver disease and gynaecomastia, and a similar trend was seen for total plasma E3.